Patient pathways - Cardiology diagnostics go private

GP commissioners shorten the journey for patients by sending them to Harley Street. By Helen Northall

Scans at a private sector facility cut costs by £1,000 per patient (Photograph: Rex Features)
Scans at a private sector facility cut costs by £1,000 per patient (Photograph: Rex Features)

Having run a highly successful community cardiology service (CCS), clinicians in Bexley, south-east London, reviewed the patient journey for the diagnosis of CHD.

The team included Bexley GPs and the consultant cardiologist in charge of the CCS.

The patient journey normally began with a referral to the rapid access chest pain clinic (RACPC) at the acute trust, and it could take up to nine months to get a definitive diagnosis.

The key concerns were the pathway's length and complexity, prolonged uncertainty for patients and, as diagnosis relied on invasive angiography, excessive cost. When seen at the trust, 55 per cent of patients undergoing angiography had normal coronary arteries, a figure much higher than the national average.

New care pathway
GP commissioner Dr Kosta Manis, the cardiovascular lead for the local GP federations, and Dr David Brennand-Roper, director of community cardiology, constructed a new pathway using 640-slice CT scanning delivered by a private provider in Harley Street in central London.

The scanner gives 99 per cent-plus predictive accuracy in diagnosing coronary disease in as little as three weeks. In piloting the new pathway, clinicians created measures for cost, patient safety, waiting times and clinical appropriateness.

The scheme, described by a previous health minister as 'the best service in Europe', has won national awards. Its driving force was primary and secondary care clinical champions.

Making the business case
Following the initial success of the new pathway - set up to respond to high levels of CHD in north Bexley - local commissioners built a business case for 'mainstreaming' the service.

A consultant cardiologist sees patients at a GP surgery. If appropriate, they are transported to the Harley Street facility the following week for 640-slice CT angiography, instead of the lengthier route to diagnosis using invasive angiography.

Patients are reviewed with their results one week later to plan appropriate management and treatment.

The average cost per patient was calculated as £1,218 - a saving of £194 per patient by contracting for a minimum 250 CT scans annually from the private sector provider.

Commissioners collected cost data for a typical patient journey through the RACPC at the local hospital. There was a high rate of angiogram referrals including patients with a low probability of disease.

Data included consultations, non-invasive predictive testing and invasive angiography where the diagnosis remained uncertain. The average cost was £2,216 per patient. It was not possible to identify total outpatient costs and, because no data were reported from secondary centres on total RACPC referrals, an assumption had to be made on total annual activity.

Based on the comparative costs of the new and existing pathways, a per-patient saving of around £1,000 was identified.

The PCT accepted the business case and an evaluation confirmed the anticipated savings yield had been exceeded.

Benefits to patients
  • Patient safety is a prime concern. The radiation dose per scan is 80 per cent less than that of invasive angiography at 0.8-1.4mSv compared with 6-10mSv.
  • Quoted morbidity (1:500) and mortality rates (1:1,000) for invasive angiography are dramatically reduced with CT angiography (1:100,000).
  • Patient waiting times are down to less than three weeks to complete the patient journey compared with six to 10 weeks for the traditional pathway.
  • Patient satisfaction, recorded using a standard questionnaire, has been consistently excellent, achieving outstanding (100 per cent) completion and satisfaction rates.

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